Conditional Primary Medicare Benefits

40.3 – Conditional Primary Medicare Benefits (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) Conditional Medicare payments may be made in liability cases under the following circumstances: a) The beneficiary has filed a claim with the liability insurer, and the MSP Contractor determines that the insurer will not pay or will not pay promptly (i.e., within 120 calendar days of receipt of the claim) for any reason except when the liability insurer claims that its benefits are only secondary to Medicare; or b) The beneficiary, because of physical or mental incapacity, failed to meet a claim filing requirement of the liability insurer. When such conditional Medicare payments are made, they are made on condition that the beneficiary will reimburse the program to the extent that the liability/no-fault insurer subsequently makes payment. When making such payments, the MSP Contractor notifies the beneficiary and the insurer of the requirement for repayment. (However, failure to do so does not relieve the beneficiary or insurer of the obligation to refund the payments.) The MSP Contractor flags all cases for possible follow-up action to recover the conditional payments. An individual’s refusal to file a claim with a liability or no-fault insurer or to cooperate with a provider, physician, or other supplier in filing such a claim is not a basis for making a conditional Medicare payment.